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Peripheral Nerve InjuryOpen Access Research article Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type Ricardo Monreal* Address: "Manuel Fajardo" Teac

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Peripheral Nerve Injury

Open Access

Research article

Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type

Ricardo Monreal*

Address: "Manuel Fajardo" Teaching Hospital Orthopedics and Traumatology Department Zapata y calle D, Vedado, CP: 10400, Havana, Cuba Email: Ricardo Monreal* - rjmg@infomed.sld.cu

* Corresponding author

Abstract

Background: Loss of elbow flexion due to traumatic palsy of the brachial plexus represents a major

functional handicap

Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve

surgery or secondary reconstructive surgery

There are various methods to restore elbow flexion which are well documented in the medical literature

but the most known and used is Steindler flexorplasty

This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow

flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened

Methods: We conducted a retrospective follow-up study of 12 patients with absent or extremely weak

elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had

undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and

wrist arthrodesis to restore elbow flexion The aetiology of elbow weakness was in all patients brachial

plexus palsy (C5-C6-C7 deficit) Data were collected from medical records and from the information

obtained during follow-up visits

Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator

and triceps), previous surgery, length of follow-up, other associated operative procedures, results and

complications were recorded

Results: The results are the follows: Eleven patients were found to have very good or good function of

the transferred muscles One patient had mild active flexion of the elbow despite the reconstructive

procedure

There were no major intraoperative complications Two patients experienced transient, intermittent

nocturnal ulnar paresthesias postoperatively In both patients these symptoms subsided without further

surgery

Conclusion: Our study suggests that in patients with C5-C6-C7 palsy where the wrist and finger

extensors are paralyzed or weaked, the flexor-pronators muscles of the forearm are strong but the triceps

is not available for transfer; Steindler flexorplasty to restore elbow flexion should be complemented with

wrist arthrodesis

Published: 11 July 2007

Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:15

doi:10.1186/1749-7221-2-15

Received: 25 April 2007 Accepted: 11 July 2007

This article is available from: http://www.JBPPNI.com/content/2/1/15

© 2007 Monreal; licensee BioMed Central Ltd

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Traction injury of the brachial plexus results in partial or

total paralysis of the upper limb, especially when there is

paralysis of elbow flexion Good hand function is wasted

if the hand cannot be maintained in a useful position

Loss of elbow flexion due to traumatic palsy of the

bra-chial plexus represents a major functional handicap

Then, the first goal in the treatment of the flail arm is to

restore elbow flexion by primary direct nerve surgery or

secondary reconstructive surgery

There are various methods to restore elbow flexion which

are well documented in the medical literature One of the

earliest procedures for restoring function to the elbow,

Steindler flexorplasty first reported in 1918 [1], is still

pre-ferred by many surgeons

This review is intended to detail the author's experience

with Steindler flexorplasty to restore elbow flexion in

patients with brachial plexus palsy C5-C6-C7 where wrist

extensors, fingers extensors and triceps are paralyzed or

weakened

Methods

We conducted a retrospective follow-up study of 12

patients with absent or extremely weak elbow flexion

(motor grade 2 or less), wrist/finger extensor and triceps

palsy associated; who had undergone surgical

reconstruc-tion of the flail upper limb by tendon transfer (Steindler

flexorplasty) and wrist arthrodesis to restore elbow

flex-ion The aetiology of elbow weakness was in all patients

brachial plexus palsy (C5-C6-C7 deficit) Data were

col-lected from medical records and from the information

obtained during follow-up visits

Five of the patients in this series had been previously

treated by surgical exploration with neurolysis, nerve

grafting or nerve transposition At the time of tendon or

muscle transfer no patient was considered a candidate for

additional nerve exploration or grafting

The wrist was fused in a position that will not be fatiguing

and that will allow maximum grasping strength in the

hand This is usually one of 10° to 20° extension, the long

axis of the second or third metacarpal shaft being aligned

with the long axis of the radial shaft (Figure 1)

When a solid wrist fusion is obtained (usually about 12

weeks) a tendon transfer (Steindler flexorplasty) is

man-datory Two points must be emphasized with regard to

this procedure: (1) Powerful activity of the

flexor-prona-tor forearm muscles and (2) proximal transfer (4–5 cm)

and fixation of a piece of the medial epicondyle (less than

one centimetre in thickness) with its attached origin of the flexor-pronator muscle group in the middle of the ante-rior aspect of the humerus (Figure 2)

Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator, flexor dig-itorum superficiales and triceps), previous surgery, length

of follow-up, other associated operative procedures, results and complications were recorded (Table 1) Flexion was measured with a goniometer from the posi-tion of complete extension so that 0° of flexion equalled completed extension In the examination of patients with shoulder fusion or trapezius transfer, care was taken to prevent the patient from using the shoulder to change position of the elbow

Wrist arthrodesis performed with the single-intramedullary-rod technique

Figure 1

Wrist arthrodesis performed with the single-intramedullary-rod technique

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Functional improvement was scored using the criteria

established by Alnot and Abols [2] Two aspects must be

kept in mind to evaluate the results obtained after

Stein-dler flexorplasty: muscular power and range of motion

Very good: Active elbow flexion against resistance (Grade

4) and range of flexion 120°

Good: Active elbow flexion against resistance (Grade 4)

and range of flexion below 120°

Mild: Active elbow flexion against gravity but not resist-ance (Grade 3) and range of flexion 80° or more

Fail: No active elbow flexion against gravity (Grade 0 to 2)

Additional operative procedures were performed to enhance function of the extremity These included two shoulder arthrodesis and four trapezius transfers to treat flail shoulder (Table 1)

Results

The average duration of clinical follow-up was 27.8 months, with a range from 4 months to 62 months There were two female and 10 male patients with an average age

at operation of 27.2 years (range 21 to 52 years)

Preoperatively, all patients had powerful activity of the flexor-pronator forearm muscles, two patients had active elbow extension grade 3 and 10 patients had no detecta-ble active extension of the elbow (grade 2 or less) The patients' assessments of the outcome showed that 11 patients were found to have very good (Figure 3) or good function of the transferred muscles and one patient had mild active flexion of the elbow despite the reconstructive procedure (Table 1)

There were no major intraoperative complications Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively In both patients these symptoms subsided without further surgery There were

Table 1: Data on the flexorplasties evaluated.

Case Age and Sex Pre operative Strength* Length of Follow-up (months) Previous Surgery Associated

Procedures Results Complications

Elbow flexors Wrist flexors FDS Pro Triceps

* Strength rated on a scale of 0 to 5

nl: neurolysis; ng: nerve grafting; nt: neurotisation

VG: very good; G: good; M: mild; F: fair

TT: Trapezius Transfer

SA: ShoulderArthrodesis

UP: Ulnar Paresthesias

FDS: Flexor digitorum superficiales

Pro: Pronators

Steindler flexorplasty: proximal transfer (4 – 5 cm) and

fixa-tion of a piece of the medial epicondyle with its attached

ori-anterior aspect of the humerus

Figure 2

Steindler flexorplasty: proximal transfer (4 – 5 cm) and

fixa-tion of a piece of the medial epicondyle with its attached

ori-gin of the flexor-pronator muscle group in the middle of the

anterior aspect of the humerus

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no wound infections or and no losses of fixation of the

transfer

Discussion

Many patients with brachial plexus injuries can be

bene-fited by neurolysis nerve grafting and neurotization

proce-dures Loss of elbow flexion after traumatic brachial palsy

represents a major functional handicap Although a direct

approach to the neurological lesion has given some

encouraging results, these can be incomplete and for this

reason tendon transfers still have an important role The

use of muscle transfer depends on the individual patient

but should always be part of an integrated program that

includes nerve repair and muscle transfers

Restoration of active elbow flexion is the chief concern in

the patient with upper or total brachial plexus paralysis

Restoration of active elbow flexion should be considered

in most cases as a higher priority than shoulder function

There are various methods to restore elbow flexion which

are well documented in the medical literature These

reconstructive procedures include proximal transfer of the

forearm flexor-pronator or wrist extensor mass [1-4]

ante-rior transfer of the triceps tendon [5-7] pectoralis major

transfer [8-10] latissimus dorsi transfer [11-13] transfer of

the flexor carpiulnaris [14] transfer of the

sternocleido-mastoid with or without shoulder arthrodesis [15] and

free muscle transfer [16]

Anterior transfer of the triceps tendon was designed for patients in whom paralysis or injury had left the flexor-pronator mass unusable for transfer

Transfer of the pectoralis major muscle to the biceps ten-don requires a grade of at least 4 of 5 for the strength of the sternal head of the pectoralis major muscle

Transfer of the latissimus dorsi muscle also requires a grade of 4 of 5 for the strength of the donor muscle and is technically demanding but results in moderate elbow flex-ion superior to that seen with other techniques

A free microneurovascular muscle transfer may be per-formed in a limited number of patients The most com-monly selected donor muscle is the gracilis This procedure is indicated when no functional muscles are available for transfer

The type of muscle transfer depends on the muscle groups remaining available Alnot [17] recommended triceps transfer in cases of triceps-biceps co-contractions, and Steindler's procedure when the elbow flexors reach only grade 2, contrarily it is contraindicated when the elbow flexors are classified as grade 0, when the wrist flexors are weak, or when wrist and finger extensors are paralyzed Sometimes it is recommended to complete Steindler flex-orplasty by a pectoralis minor transfer in some C5-C6-C7 palsies

In general proximal advancement of the forearm flexor/ pronator muscle group should be considered as the initial treatment in all patients because of its simplicity and lack

of donor deficit According to Segal, Seddon, and Brooks [18], when the pattern of paralysis is such that a free choice of procedures is possible, the Steindler flexorplasty

is preferable Carroll [6] advises against transferring a muscle arising from the medial epicondyle to restore hand function until after any indicated flexorplasty has been done and the strength and function of the trans-ferred muscles have been regained A modified Steindler flexorplasty was used by Chen W [19] to restore elbow flexion in 8 patients with post-traumatic flail elbow and the results were not compromised in patients whose flexor tendons had been transferred for wrist and finger exten-sion

Brunelli GA et al [20] recommend a modified Steindler procedure to restore elbow flexion The modifications were designed to avoid the phenomenon of the patient having to make a fist in order to obtain elbow flexion (Steindler's effect) According with the authors, Steindler flexorplasty is indicated in upper plexus lesions (C5-C6); other transfers are more appropriate for lower plexus pal-sies

Case 7, after flexorplasty of the right elbow and arthrodesis

on the right shoulder

Figure 3

Case 7, after flexorplasty of the right elbow and arthrodesis

on the right shoulder Active elbow flexion to 135 degrees

(Very good result) allows positioning of the hand to the head

and face for independent self-care

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There is general agreement regarding the efficacy of the

Steindler flexorplasty Despite varying criteria, a number

of authors [1-4] have reported a 70 to 90 per cent success

rate with this procedure We agree that it is the procedure

of choice for a patient who has paralysis of the biceps

bra-chii and brachialis, a functional hand, and sufficient

fore-arm flexor power to warrant transfer

Proximal transfer of the medial epicondylar muscles is an

important adjunct in the rehabilitation of the paralyzed

upper extremity, when there is adequate power of this

muscle mass and full extension of the elbow is not

required for transfer or ambulation When the medial

epi-condylar muscles are weak or full extension of the elbow

is essential for transfer or ambulation, an alternative

pro-cedure must be considered

An isolated lesion of C7 does not cause a complete

mus-cular paralysis because the proximal muscles innervated

by C7 are also innervated by C6 (pronator teres, teres

major, flexor carpi radialis, triceps, extensor indicis and

digiti minimi proprii) while the lower muscles innervated

by C7 are also innervated by C8 (palmaris longus, triceps,

extensor carpi ulnaris, abductor pollicis longus, extensor

pollicis brevis, extensor pollicis longus, flexor carpi

ulnaris) The sensory function is only very slightly

involved if C7 is involved in isolation because of the

over-lapping of C6 and C8 However, if one contiguous spinal

nerve or trunk is involved, the muscular paralysis

becomes evident [21]

Increase in elbow flexion strength comes at the expense of

increased passive moments for wrist flexion and forearm

pronation caused by the increased excursions of these

muscles imposed by the transfer The only way to

counter-act the tendency for passive muscle forces to flex the wrist

is with active wrist extension [22]

The treatment of choice depends of the injury In C5-C6

palsies with no elbow flexor function (grade 0–2);

Stein-dler flexorplasty and triceps transfers have always

pro-vided good results In C5-C6-C7 injuries, with no elbow

flexor activity (grade 0), the triceps can be used if it

receives a dominant innervation from C8-T1 but when the

elbow flexors are grade 2, the Steindler flexorplasty is

usu-ally sufficient with active wrist extension or fused wrist

Our study suggests that in patients with C5-C6-C7 palsy

where the wrist and finger extensors are paralyzed or

weaked, the flexor-pronators muscles of the forearm are

strong but the triceps is not available for transfer; Steindler

flexorplasty to restore elbow flexion should be

comple-mented with wrist arthrodesis

References

1. Steindler A: A Muscle Plasty for the Relief of Flail Elbow in

Infantile Paralysis Interstate Med J 1918, 25:235-241.

2. Alnot JY, Abols Y: Réanimation de la flexion du coudepar

trans-ferts tendineux dans les paralysies du plexus brachial de

l'adulte Rev Chir Orthop 1984, 70:313-323.

3. Mayer L, Green W: Experiences with the Steindler

Flexor-plasty at-the Elbow J Bone Joint Surg (Am) 1954, 36-A:775-789.

4. Kettelkamp DB, Larson CB: Evaluation of the Steindler

flexor-plasty J Bone Joint Surg (Am) 1963, 45-A:513-8.

5. Carroll RE: Restoration of flexor power to flail elbow by

trans-plantation of triceps tendon Surg Gynecol Obstet 1952, 95:685-8.

6. Carroll RE, Gartland JJ: Flexorplasty of the elbow: an evaluation

of a method J Bone Joint Surg (Am) 1953, 35-A:706-l0.

7. Carrol RE, Hill NA: Triceps transfer to restore elbow flexion: a

study of fifteen patients with paralytic lesions and

arthro-gryposis J Bone Joint Surg (Am) 1970, 52(2):239-244.

8. Carroll RE, Klelnman WB: Pectoralis major transplantation to

restore elbow flexion to the paralytic limb J Hand Surg (Am)

1979, 4(6):501-507.

9. Clark JMP: Reconstruction of biceps brachii by pectoral

mus-cle transplantation Br J Surg 1946, 34:180-l.

10. Tsai TM, Kalisman M, Burns J, Klelnert HE: Restoration of elbow

flexion by pectoralis major and pectoralis minor transfer J

Hand Surg (Am) 1983, 8(2):186-190.

11. Hovnanian P: Latissimus dorsi transplantation for loss of

flex-ion or extensflex-ion at the elbow: a preliminary report on

tech-nic Ann Surg 1956, 243:493-9.

12. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow

flexion: an appraisal of eight cases J Bone Joint Surg (Am) 1973,

55(2):1265-1275.

13. Moneim MS, Omer GE: Latissimus dorsi muscle transfer for

restoration of elbow flexion after brachial plexus disruption.

J Hand Surg (Am) 1986, l1(1):135-139.

14. Ahmad L: Restoration of elbow flexion by a new operative

technique Clin Orthop 1975, 106:186.

15. Bunnell S: Restoring flexion to the paralytic elbow J Bone Joint

Surg (Am) 1951, 33-A:566-7.

16. Doi K, Sakai K, Kuwata N, Ihara K, Kawai Sh: Reconstruction of

fin-ger and elbow function after complete avulsion of the

bra-chial plexus J Hand Surg (Am) 1991, l6(5):796-803.

17. Alnot Jy: Elbow flexion palsy after traumatic lesions of the

brachial plexus in adults Hand Clinics 1989, 5:15-22.

18. Segal A, Seddon HJ, Brooks DM: Treatment of paralysis of the

flexors of the elbow J Bone Joint Surg (Br) 1959, 41-B:44.

19. Chen WS: Restoration of elbow flexion by modified Steindler

flexorplasty International Orthopaedics 2000, 24:43-46.

20. Brunelli GA, Vigasiol A, Brunelli GR: Modified Steindler

proce-dure for elbow flexion restoration J Hand Surg (Am) 1995,

l6-A:743-746.

21. Brunelli GA, Brunelli GR: A fourth type of brachial plexus lesion:

The intermediate (C7) palsy J Hand Surg (Br) 1991,

16-B:492-495.

22. Saul KR, Murray WM, Hentz VR, Delp SL: Biomechanics of the

Steindler Flexorplasty Surgery: A Computer Simulation

Study J Hand Surg (Am) 2003, 28-A:979-986.

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